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12.0 Ear, Nose and Oropharynx

12.0 Ear, nose and oropharynx

12.1.1 Otitis externa

Anti-inflammatory preparations with antibacterial   
GREEN       Locorten-Vioform® eardrops  
GREEN      Betnesol® N ear drops
GREEN      Otomize® ear spray   
GREEN      Fluocinolone 0.025% & neomycin 0.5% cream, ointment (Synalar N®)   
                  (For Otitis Externa only) 
 
Chronic otitis media and otitis externa (necrotising) 
RED           Ciprofloxacin 0.3%, dexamethasone 0.1% ear drops (Cilodex®) 
                          ENT use only -  not to be prescribed in Primary Care
RED          Ciprofloxacin/fluocinolone  3mg/ml+ 0.25mg/ml ear drops  (Cetraxal Plus®) 
                          ENT use only - not to be prescribed in Primary Care
RED           Triamcinolone, Neomycin sulfate, gramicidin, nystain (Otocomb® ointment)
                         ENT use only - off license use, not to be prescribed in Primary Care
 
The BNF considers the following product to be less suitable for prescribing.
GREEN      Sofradex®ear/eye drops     
 
Anti-infective preparations  
Use of gentamicin is contraindicated in those with perforated ear-drum. 
See BNF section for further advice. 
GREEN      Gentamicin ear/eye drops 0.3% 
RED           Clotrimazole 1% drops (specialist use only)   
 
 

12.1.3 Removal of ear wax

Wax can be softened with simple remedies prior to syringing. 
GREEN      Olive Oil
GREEN      Sodium Bicarbonate 5% ear drops    

12.2.1 Drugs used in nasal allergy

Allergic rhinitis and nasal congestion can be relieved by topical corticosteroids.  
Topical antihistamines are probably less effective.
Antihistamines  
GREEN      Azelastine aqueous nasal spray 140 microgram/metered spray    
 
Corticosteroids:     
Twice daily preparations
GREEN      Beclometasone nasal aerosol 50 micrograms/metered spray

Once daily preparations  
First line (licensed for use in adults and children  6 years)       
GREEN      Triamcinolone aqueous nasal spray 55microgram/metered spray 
 
Alternative (additionally licensed for children  4 years)
GREEN      Fluticasone aqueous nasal spray 50 microgram/met spray  
 
For the treatment of nasal polyps 
GREEN      Mometasone furoate nasal spray 50 micrograms
 

12.2.2 Topical nasal decongestants

For use only by anaesthetists for nasal intubation. Not recommended for general use. 
RED           Xylometazoline nasal spray 0.1% 
 
For use only by ophthalmologists to treat peri-orbital cellulitis in children.
RED           Xylometazoline nasal drops 0.05%     
 
For non-allergic watery rhinorrhoea 
GREEN      Ipratropium bromide nasal spray 0.03%
 

12.2.3 Nasal preparations for infection

Epistaxis
RED           BIPP on gauze 
 
Nasal staphylococci
Elimination of organisms from the nasal vestibule can be achieved but re-colonisation frequently occurs.
GREEN      Naseptin® cream (as part of MRSA eradication)
GREEN      Naseptin® cream (as part of MRSA eradication)

12.3.1 Drugs for oral ulceration and inflammation

Oral ulceration may be treated with corticosteroids.
 
New advice on oral salicylate gels in under 16s from the MHRA           
The main products affected are Bonjela®  and Bonjela®  Cool Mint Gel.
The new advice recommends that these products should not be used in  those under 16 years of age. This is due to salicylate salts having the same effect on the body as aspirin which is already  contraindicated in children and young people under 16 years of age.
 
GREEN      Bonjela® oral gel      
GREEN      Hydrocortisone pellets 2.5mg     
AMBER     Gelclair® - only for acute chemotherapy/radiation induced mucositis
AMBER     Betamethasone 500 microgram soluble tablets     
                  This product is used in oral surgery practice only: dissolved in water and used as a mouthwash
 
Treatment of inflammatory conditions
GREEN      Benzydamine (Difflam®)
                   oral rinse 0.15%, spray 0.15%   
 

12.3.2 Oropharyngeal anti-infective drugs

The most common cause of a sore throat is a viral infection which will not benefit from anti-infective treatment. 
Chlorhexidine mouthwash renders nystatin ineffective, therefore wait 15-30 minutes before applying nystatin.
 
Fungal infections 
First line:
GREEN      Miconazole oral gel 24mg/mL    
 
Prescribers are reminded that there is a significant interaction between warfarin and miconazole -including the oral gel, 
resulting in an increased INR. This product should therefore be avoided in patients taking warfarin.
 
Second line or for infants under 4 months or patients taking warfarin:   
GREEN     Nystatin  
                  suspension 100,000 units/mlL   
                  pastilles 100,000 units                                                                                                        


12.3.3 Lozenges and sprays

There is no convincing evidence that antiseptic lozenges have a beneficial action and they sometimes irritate and cause
sore tongue and sore lips. Some of these preparations also contain local anaesthetics which relieve pain but may cause
sensitisation. The following products are stocked within the hospitals for symptom relief only but are not generally 
recommended for prescribing.
 
RED           Dequadin® lozenges 


12.3.4 Mouth-washes, gargles, and dentifrices

For use if a patient has, or is at risk of, an oral infection. Chlorhexidine inhibits the formation of plaque and may be 
useful when tooth-brushing is not possible. (see ELHT Mouth Care Policy May 2003)
 
GREEN      Chlorhexidine mouth wash 0.2%      
GREEN      Chlorhexidine oral gel 1%     

12.3.5 Treatment of dry mouth           

Endorse prescription with ‘ACBS’ – patients suffering from dry mouth as a result of having (or having undergone) radiotherapy, or sicca syndrome, apply to gums and tongue as required.

GREEN      Glandosane® synthetic saliva spray    
                   (acidic pH – try to avoid for patients with their own teeth in situ)
GREEN      Biotene Oralbalance® - saliva replacement gel  
                   (pH neutral when used in vivo)
GREEN      Saliveze®  synthetic saliva spray    
                   (pH neutral)
AMBER      Pilocarpine 4% eye drops 
                   Unlicensed use - refer to Lancashire and South Cumbria Specialist Palliative Care Prescribing